Bhutan surprised the world in April, 2021. The tiny kingdom on the eastern slopes of the Himalayas started its COVID-19 vaccination rollout on March 27, 2021, and within 2 weeks, it had reached more than 90% of the adult population eligible for vaccination (adults 18 years and older). The proportion was a larger share of its population than well-resourced nations in the Middle East and Europe that started their vaccination campaigns months before. Although its immunisation drive benefitted from a small total population of around 750 000 people, vaccinating over 470 000 eligible adults with their first dose of COVID-19 vaccine in such a short time was still impressive.Its unconventional approach to vaccine rollout also made headlines. The highly religious, majority Buddhist country received 550 000 doses of Covishield, a version of the Oxford-AstraZeneca COVID-19 vaccine, as a donation from the Government of India in January and March, 2021. However, it waited until an auspicious date and time in Buddhist astrology to start vaccinating. On Facebook on March 27, the Prime Minister's Office, announced: “Prayers filled the hall of Lungtenzampa Middle Secondary School this morning. At the auspicious time of 9.30am, Ninda Dema, a 30-year-old female born in the monkey year, was administered the first jab of the COVID-19 vaccine in the country. Sister Tshering Zangmo, also born in the same year and of same age, in keeping with astrological requirement handled her immunization…With this, Bhutan's nationwide COVID-19 vaccination program kicks off.”

In the run-up to the vaccination drive, Bhutan's Prime Minister Lotay Tshering, a surgeon who still practices at the weekend, held regular social media broadcasts reassuring the population about various aspects of COVID-19 vaccination to counter vaccine hesitancy. WHO assisted in the development of the vaccine rollout plan and training materials for vaccinators. It also provided technical and financial support to train health workers across Bhutan ahead of the campaign. A national corps of over 4500 orange-clad volunteers called Desuung were also crucial; they helped establish more than 1200 vaccination sites in the country. Home-based vaccination services were provided for those registered as having mobility or other medical issues. A day prior to the nationwide rollout, a mock drill was done in the capital, Thimphu, and the lessons learned were issued to all 20 districts to aide their implementation. Health Minister Lyonpo Dechen Wangmo, an epidemiologist by training, told the national newspaper Kuensel that the medical experience within government has benefitted the country's COVID-19 response: “It helps in making rational and well-informed decisions when you have in-depth knowledge of the subject yourself.”

Tshokey Tshokey, consultant clinical microbiologist in the Jigme Dorji Wangchuck National Referral Hospital in Thimphu and a member of Bhutan's Technical Advisory Group for the COVID-19 response, credits existing systems for Bhutan's successful vaccine rollout. “Bhutan has…high coverage of childhood vaccination. Every health centre in the country, including the remotest Basic Health Units, have the required cold chain system, trained health workers, and the vaccine supply chain management in place…The country also has experiences of conducting several national and sub-national immunization campaigns in the past. Taking cue from all these systems and experiences, the preparation for the nationwide COVID-19 vaccination was not difficult”, he told The Lancet Respiratory Medicine.

Other aspects of Bhutan's COVID-19 response are noteworthy. In January, 2020, the country started drafting its National Preparedness and Response Plan, the health ministry stationed thermal scanners and began surveillance of respiratory symptoms at Paro International Airport, and the national Health Emergency Operations Center was activated. “Considering early preparedness as the key to success, Bhutan prepared and implemented its measures very early in the pandemic”, says Tshokey. For example, he notes “The Royal Center for Disease Control (RCDC), [then] the only medical laboratory in the country with RT-PCR capacity, started COVID-19 testing as early as January 2020, long before many countries had the testing capacity.”On March 5, 2020, the country confirmed its first case of COVID-19 in an American tourist. Rapid contact tracing took place: the patient's laboratory results were available at midnight and by 0600 h all his primary contacts were identified, isolated, and placed in quarantine. Bhutan then barred the entry of all non-nationals and introduced a mandatory quarantine in designated hotels for anyone entering the country to prevent importation of cases. In March, the Bhutanese Government also started issuing daily COVID-19 updates and promoted face masks, hand hygiene, and physical distancing. The country experienced two local outbreaks of COVID-19, the first in August, 2020, both of which led to national lockdowns. The lifting of lockdowns was gradual and phase-wise and only ended after containment of the outbreaks, with no new cases confirmed from rounds of mass testing. “We learned a lot from [the] unlocking experience in many countries, and we realised for a small nation like ours, we have to be very, very cautious”, said Wangmo in a webinar for the non-governmental organisation the Bhutan Foundation on Sept 14, 2020.In 2019, the country had around 3000 health workers and 376 medical doctors (and only one ICU-trained physician), far fewer than it requires to meet the WHO recommended doctor-population ratio of 1:1000. Wangmo said “we have put a lot of effort in containing and preventing our health workers from getting infected” from COVID-19. The country developed containment protocols for its major hospitals to avoid them becoming a hub for infection and to prevent community transmission. Before entering hospital premises, every health worker and patient undergoes COVID-19 testing. Even before Bhutan's first positive COVID-19 case, every patient admitted to hospital with acute respiratory infection was tested through the country's newly developed COVID integrated influenza surveillance system.Bhutan's northern border with the Tibet region of China has been closed for decades, but to the south lies a porous border with India, which is experiencing a devastating second wave of COVID-19. In mid-April 2021, Bhutan suspended the import of foreign workers as a temporary measure due to concern over importation of the virus from India, especially given the variants of SARS-CoV-2 that have been related to India's COVID-19 surge. As of May 25, 2021, Bhutan has only reported 1411 confirmed cases and one death from COVID-19.The country's preparedness started before the pandemic. In 2018, Bhutan, with the help of WHO, underwent an evaluation of its emergency readiness and established its Health Emergency Operations Centre. Medical Camp Kit tents, which can be deployed quickly if there is disruption in providing services in health-care facilities, were also invested in. The tents have been used as influenza clinics to treat patients with respiratory disease symptoms and isolate them from other patients to prevent disease spread, including for COVID-19. In November, 2019, WHO in collaboration with the Bhutanese Ministry of Health did a simulation exercise at Paro International Airport. The scenario? A passenger arriving from abroad with a suspected case of a “coronavirus disease”. The exercise involved national authorities including armed forces, police, civil aviation, customs, health officials, and the Desuung, and aimed to identify gaps in preparedness. A month later, the outbreak of the novel coronavirus started in Wuhan, China.Bhutan is a lower-middle income country that has reduced poverty by two-thirds in the past decade, according to the World Bank. It increased its GDP per capita to US$3398 in 2018, exceeding South Asia's average of US$1905 in the same year. However, the country is famous for its other measure of progress: Gross National Happiness, a philosophy that gives high importance to non-economic aspects of wellbeing. Bhutan is just 39 000 km2 and about two-thirds of the country is covered with forests, which are protected by legislation. Such an environment and measures have contributed to Bhutan becoming the world's only carbon-neutral country. In fact, Bhutan is carbon negative. However, the country's second biggest risk factor driving death and disability is still air pollution, according to the Global Burden of Diseases Study (GBD) 2019. Exhaust and industry emissions and smoke from wood stoves are some of the primary sources of air pollution in Bhutan.Bhutan ratified the WHO Framework Convention on Tobacco Control (FCTC) in 2004 and that year it became the first country in the world to enact a nationwide ban on the sale of any form of tobacco products. In 2010, it went further, passing the Tobacco Control Act, which banned cultivating, manufacturing, and trade in tobacco and its products. The country allows smokers to import controlled amounts of tobacco products but only after paying large duties and taxes. However, smoking is still a problem. Chronic obstructive pulmonary disease was the second leading cause of death in the country and third leading cause of death and disability combined in 2019. Worryingly, the prevalence of tobacco use among Bhutanese students aged 13–15 years increased from 18·8% in 2009 to 22·2% in 2019, according to the Global Youth Tobacco Survey report for Bhutan in 2019, which is higher than the regional average. The situation might worsen too. In 2020, the prime minister lifted the ban on tobacco sales to reduce the demand for smuggled cigarettes from India and lower the risk of cross-border contagion from COVID-19. Smokers can now buy tobacco products from state-owned duty-free outlets, and they are listed as essential products available during lockdowns. The government has said the reversal of the ban is temporary.Publication HistoryIdentification

DOI: https://doi.org/10.1016/S2213-2600(21)00268-X

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